22952 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Prato lderolflr.11u PElU&TNO.
Bn°°"g"'dra` 22952
epi-o�:no ~\ pa*%� aphosl Or� CITY OF Cr— l
C anendcesNan,: APPLICATION I PERMIT
�.Cr 3SQS\ BWLDINGFT.B=iucALPLumB[NGMECHANwAL CATEGORY CO R
1 A BM/Engln,er. Lie N 11
a
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PFRMITISSUANCE ❑ El ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirm that lam accrued undarpravblmsofChapbr9(mmmer APPLANCESRESMEMTAL JOB Itlgwlth5eRbn700a)ofDMdm3oftheBuYneoues
dR donsCMe,and \
Ikrs blabs fnm.nddfed. PANELS —�O\\P..��
Lima Cbr Lk.a J
Date �3 \Cowaaor
ARCHITECT'S DECLARATION 2014000
rs M I understand my plaro slag be used as public tamda. OVERIMAMPS SO.Fr.FLOOR AREA S/SO.FF.
Ep< Licensed Pmfe®bul SIGNSELBCTRICAL
OWNER-BUILDER DECLARATION ST:CIALCIRCUET/Mir
1 S lherebyafaem that l am wompt from the Conemctole Lkas law for the
7 Appp
following reason.sMlcau7ml$Busbs and Professional Code Any city or FD q mentywhkhrequhuapemtlemmmlmc4aller,lmpnwe,demolbh,mmpalr '•MECFRORPOLEINSI'.
37 anym.mmpe"Wfbbna aborequimtheapplk=tfwsuchpe.*w POWER DEVICES3
like
.Igned statement that be b licensed pumant to the provision,of the
ConlcartalsLken,e law(Clupter9(mnurenduug with Bodies 7000)dDiviSIMMINGPDOLELECTRIC
-
t,,,��5 abed -BuslnsandPrdar.broCode)orthehebasemptthemtmmand VALUATION
the heals fee the alleged eumptlon. Any violation of Stolon 70115 by any
X appllmnt fees permit ul*rtathea licatrite•Wil OUTLB75SWITCHESFIXIUR6
PP penalty d���smlhan
frvU L a.redddWshe pro NEW RFSmINDAL ELBCTR_ F[fFT. STORIES TYPISCONSTRI)CMN
�n Lanowanr ofthe
Work and
my employees With wagn,uthelrule
6 mm(Sm,7 Kwuldotk wmkaeadthe,Codumbmewtandedmo#st d for
Law
O ml.a(Sm,70KBuwmsaM Rofmsbn, hobullk CaMatlm'e Lceroe Lw
$ dnrondappty loanown,r ofpropertyobuild.eeImprover,
powideermtuand
�^
who domsuehweekhimzBcalhrwgh NaawnempbyeesPmvtledthat such OCC.CI�UP RES UNDS
bnpm m M mm intmdcdwcfkedfwmle.14however,lhebulldingm TOTAL
lmprovemontbsoldwkhbon,ymrdcompkUmtheo bagderwgihave
UIRIlurden of proving that he din not build mlmprove for purpose ofsale.). QfY. PLUMBING PERMIT FEE
LJ 1 u owner d the property,am exclusively,mnbMwg with Ikmwd bT+ODDmNE APN
omtraetnew mrstrud Business miset(See 70114 Businand Prufenbn,Cade. PERMIT ISSUANCE `
no Cotdmdorb Lio n e IoW dm ant apply to an owner of property who ALTER-DRAW k VENT WATER(FA)
builds oves or Impresses Ihnm
son,and who rveddsuch for pPjeda with
Ilameed pursuant w theCmbadulaLlcas Law. FEE SUMMARY
1 am exempt under See B It P C for this masan BACK FLAW PROTSCL DEVICE
QUTSIGFFEFS
DRAINS•FLOOR RODS,AREA,GOND. SANITARY Y_ N
• Owner Owe R ff A
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCFfOOLTAX Y_ N_
❑1 hereby affirm AMI Co I have•cedfka c d menu w d4Nsam,el e. �o RECEIPT a
3BKLabafWoekem'Compestlmlreuranmeea cartNled mpythenwf sees. GAS EA.SYSTQd-1 INCA 0U1Lm PARKFPB Y N
3800,lab CJ
Pdky B y GAS EA.SYSTEW43VFRd(EA) RECEFr 1
nBUILDING DIVISION FEES
adifed copy b herebytumbhM. CREASE/WDUSTRL WASIE INTERICEMOR PLANCHECK FEE
CertNed copy bland with IM ally Inspection dMslm.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE7RAP PAID .
P.bZj=jtheLWorkwa
SATIO URANCfi SEWBWSAND'ARYMRM EA.200FL Date Recei t#
Oglia b/eeon,hundred dalton
(St wArmei♦fiATFx w/vFxl'/EI.�TR ENERGY FEE Y N_
mnm t feewhchthbpemdtbi...d,
hall not ner n u to herons sub)en to the WATERSYS[FM/'IRBATINC
mksb.Dee PAID
Zz hATTCfter making Cedficam,fBumpibn,ym NEW RESIDESMAL RMB. SOFT. Date ReceI t#
shouldoukem'Comperoalbn provbiuro fthe Labor TOTAL
hU CadgyoumutfMbwahmmp"thmchproWbmorthbpemdtshallbe
� 9 deemed invoked. BUILDING FrE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
tl lhembyaabrruthat them In amrometlm lendbgagerey forthe pmlm m ELECTRIC FEE
M Z a oftheworkforwhkhthbpmMblsed Om3OP/,GT(7rAf.:..CJ a� —
LLO Landee,NamePLUMBING FEE
h Leadees Add. QTY. MECHANICAL PERMIT FEE MECHANICAL TICE
O w loMifythelhavemadthbappllatbnandetablbattheabmLafee rim
bmmd.lagm Wb phywahaaeityandaountyordinmmmd rabhws PERMIT ISSUANCE FEES PAID:
Nmlating tobuiMbugmsrodlary and hereby uthMu reprcaentativn dthls
F Z eityloanbrupon the abme-mentbmd property for Inspection pwposem ALTERORADDTOMECH.
(We).pealo uv lMemdfyandkeep Wrmlanthe Chy fC pMwo Date Recd t#
agabatibbutiMjudgment,me..nduponmwhkhmylnuywayamras AIRHANDUNGUNIr O'OIOp00CFM) SUBTOTAL:
Id w—mVepcma[th paling of this Pam F
L`7�gY'as
tL AIR RIiANDLNC UNIT(OVER IQWOCFN) CONSTRUCTION TAX
Siguture Applicant/Co rMor - �6ate EXKAUSTHOODDV/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WE[the applicant orfuwre building cmupont Mom or handle haeadou. HEATING UNIT fro 100,000 a71D Date RL'ccl #
malarial m cleared by the Cupertino Municipal Cade,Chapter 911 and we
Health and Safety Code Shim MISM(a)T HEATING UNIT(OVER I(EUED BTU TOTAL:
❑Yen r1a�-,1 No ISSUANCE DATE
Wle.dth.n,d .k= blhuMsasd.Rnlun equlpmA mdevirn VENTILATION FAN sadCLB REBID)
whkhemitmge naabmMtaMrodsaa dearod by1M Bay Area Ab
• orality Marogement Dirt No B06ERmptr OMP DR,oE,EEO BTU PAID
I�YT) I-I No
re read the hararMaty CcrSWJo,lmmenbund.n,125ter G9F of BOd[ILCOMPtDVERIgD,00g BilD
the Gltiomb FWlth4 ildlag oes,SMbro 255,harm33and255M.1 F 8 1991
understand NyWothe Wiwi aMoft erequiresmswich that It maty NbWRmDFN1TAI MECH SQ.FT. NOVV V 1e7,7
rnporoEdlityw ndlly the onupad dlhe requlrenem.whkh caul he nag
prierto issue=daCertiacabdoattpamy. CITY OF U0tHI ,
Owneree authorbN agent Dab
TOTAL ISSUED BY:3a65_ 1 1
OFFICE COPY